Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in Patients With Previous Bariatric Surgery: Is It Safe and Feasible?

BACKGROUND: Obesity is widely recognized as a major health concern and a leading cause of preventable death. The correlation between obesity and breast cancer has been thoroughly described by several authors. Bariatric surgery is often associated with redundant abdominal tissue, often leading patients to consider body-contouring procedures. Autologous tissue breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has advantages because it is tissue that is normally discarded during postbariatric body contouring. METHODS: We conducted a retrospective chart review of 18 DIEP flaps performed by the senior author in 9 patients for breast reconstruction between February 2008 and May 2013. All patients underwent mastectomies. All patients underwent bariatric surgery preceding breast reconstruction. Breast reconstruction was performed immediately in 13 cases and delayed in 5 cases. RESULTS: Mean age of the study population was 44.6 years (range, 41-57 years). The mean maximum body mass index of the patients was 44 (range, 37.6-52.1), and the mean current body mass index at the time of the reconstruction was 30.7 (range, 24.3-38.1). No intraoperative complications were reported. No fascia or muscle was taken during flap dissection. Mean operative time was 632 minutes (range, from 480 to 750 minutes). Average hospital stay was 4 days. No partial or total flap loss was reported. There were no postoperative hernias or bulges at the abdominal donor site. CONCLUSIONS: This series represents the largest group of patients undergoing DIEP flap breast reconstruction after bariatric surgery. In the hands of experienced microsurgeons, breast reconstruction with the DIEP flap in postbariatric patients represents a low-risk option with high satisfaction.

Abdominoplasty and Breast Augmentation with Outpatient Cosmetic Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: The authors describe the use of deep inferior epigastric perforator (DIEP) flaps in outpatient cosmetic breast augmentation. METHODS: The authors reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. All patients underwent an early recovery protocol including microfascial incisions to harvest the DIEP flaps and rib preservation in addition to early recovery after surgery protocols with intraoperative anesthetic blocks. RESULTS: Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients reported preoperative dissatisfaction with their abdomen and breasts. Microfascial incisions for single perforator abdominal flaps ( n = 17) averaged 1.7 cm (range, 1.3 to 2.4 cm) and flaps with multiple perforators ( n = 5) averaged 2.4 cm (range, 2 to 2.5 cm). Dissection of recipient internal mammary artery vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses, major complications, or take-backs were reported. CONCLUSIONS: Patients who desire abdominoplasty and augmentation are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. The early recovery protocol allows the surgeon to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with excellent results and no total or partial flap losses, offsetting the high costs associated with the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Bilateral Outpatient Breast Reconstruction with Stacked DIEP and Vertical PAP Flaps.

BACKGROUND: Stacking free flaps for breast reconstruction is far from novel, even in the case of a deep inferior epigastric perforator (DIEP) plus profunda artery perforator (PAP) configuration, where the latter is always described in the traditional transverse configuration. We present a series of consecutive patients undergoing bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. METHODS: Patients with inadequate abdominal donor tissue were offered the possibility of a stacking breast reconstruction. The DIEP flap was harvested via microfascial incisions, whereas the vertical PAP flap was harvested in the lithotomy position, following the course of the gracilis muscle. RESULTS: In total, 28 consecutive patients with a mean BMI of 24.9 underwent bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. The internal mammary artery and vein were used as recipient vessels in all 56 stacked flaps. Fifty-three PAP flaps were anastomosed to the distal portion of the (primary) DIEP flaps utilizing a sequential flap anastomosis technique, and one DIEP flap was anastomosed to the distal portion of the (primary) PAP flap. Hospitalization for the initial eight patients averaged 35 hours, whereas the following 20 patients were discharged within 23 hours. There were no postoperative takebacks or vascular complications. CONCLUSIONS: Stacked DIEP/PAP flaps offer an excellent option for patients who require more volume than available from DIEP flaps alone. When compared with transverse PAP flaps, the vertical PAP offers excellent variability of volume and ease of shaping to allow for excellent results, while minimizing donor site tension in the seated position and preserving the gluteal fold.

Use of Single-recipient Vessels for Cross-chest Abdominal Flap-based Breast Augmentation as an Outpatient.

Breast reconstruction with autologous tissue following mastectomy for breast cancer has become the standard of care. Microvascular breast augmentation is an alternative for patients with failed breast prostheses, including painful capsular contractures or poor cosmetic outcomes. We present a series of 4 patients who underwent microvascular breast augmentation with cross-chest flap recipient vessels. METHODS: We perform a bilateral DIEP flap reconstruction in an outpatient setting following a modified recovery protocol, focused on decreasing postoperative pain and narcotic requirements, allowing early ambulation and discharge. This includes harvest of the flap via abdominal microfascial incisions and rib-sparing vessel dissection. Cosmetic microvascular augmentation of the contralateral breast was performed via cross-chest flap recipient vessel anastomoses, where the pedicle was tunneled across the chest and anastomosed to the primary flap. RESULTS: Four patients underwent flap-based breast augmentation with cross-chest recipient vessels. Two patients underwent immediate DIEP flap breast reconstruction of the affected side and contralateral flap-based augmentation, while 2 patients underwent bilateral breast augmentation with DIEP flaps for cosmetic purposes due to undesired cosmetic results following implant-based augmentations. No intraoperative complications were reported, and all patients were discharged within 23 hours without signs of flap compromise or need for operative take-backs. Mean follow-up was 23 weeks. CONCLUSIONS: The DIEP flap is recognized as an option for breast augmentation, although its limitations are several, including the pain and recovery associated with autologous tissue-based breast reconstruction. Enhanced recovery protocols help reduce this burden, making it more acceptable and feasible.

Outpatient Microsurgical Breast Reconstruction.

BACKGROUND: The extensive nature of perforator-based breast reconstructions, combined with the need for postoperative flap monitoring, often leads to long hospitalizations. We present an early report demonstrating the feasibility and advantages of a modified operative technique and recovery protocol, allowing us to perform outpatient breast reconstructions with the DIEP flap. This follow-up comprises the experience gained, which is expanded to other perforator-based flaps and not limited to DIEP breast reconstructions. METHODS: We have implemented a general protocol in patients undergoing breast reconstruction with autologous flaps, promoting early mobilization and discharge by improving postoperative pain and decreasing opioid requirements. This protocol includes intraoperative local anesthesia, a microfascial incision for DIEP harvest with rib preservation, along with prophylactic anticoagulation. RESULTS: Ninety-two consecutive patients underwent autologous tissue-based breast reconstruction with DIEP, IGAP, and PAP flaps. No intraoperative complications were reported. All patients were discharged within 23 hours, without evidence of flap compromise. One patient required operative takeback for evacuation of a hematoma on postoperative day 4. No partial or total flap losses were documented. The aim of any procedure should be to get to the patient back to the preoperative status as quickly as possible, as prolonged hospitalizations are associated with higher incidences of infection, deep venous thrombosis, overall dissatisfaction, and higher overall costs of care. CONCLUSIONS: By using a modified operative technique, multimodal pain control, and postoperative anticoagulant therapy, outpatient perforator-flap-based breast reconstructions can be performed with high success and low complication rates.

Wearable positive end-expiratory pressure valve improves exercise performance.

We tested a PEEP (4.2 cmH2O) mouthpiece (PMP) on maximal cycling performance in healthy adults. Experiment-1, PMP vs. non-PMP mouthpiece (CON) [n  = 9 (5♂), Age = 30 ±â€¯2 yr]; Experiment-2, PMP vs. no mouthpiece (NMP) [n = 10 (7♂), Age = 27 ±â€¯1 yr]. At timepoint 1 in both experiments (mouthpiece condition randomized) subjects performed graded cycling testing (GXT) (Corival® cycle ergometer) to determine V ˙ O2peak (ml∗kg∗min -1), O2pulse (mlO2∗bt -1), GXT endurance time (GXT-T(s)), and V ˙ O2(ml∗kg∗min -1)-at-ventilatory-threshold ( V ˙ O2 @VT). At timepoint 2 72 h later, subjects completed a ventilatory-threshold-endurance-ride [VTER(s)] timed to exhaustion at V ˙ O2 @VT power (W). One week later at timepoints 3 and 4 (time-of-day controlled), subjects repeated testing protocols under the alternate mouthpiece condition. Selected results (paired T-test, p<0.05): Experiment 1 PMP vs. CON, respectively: V ˙ O2peak â€‹= â€‹45.2 â€‹± â€‹2.4 vs. 42.4 â€‹± â€‹2.3 p<0.05; V ˙ O2@VT â€‹= â€‹33.7 â€‹± â€‹2.0 vs. 32.3 â€‹± â€‹1.6; GXT-TTE â€‹= â€‹521.7 â€‹± â€‹73.4 vs. 495.3 â€‹± â€‹72.8 (p<0.05); VTER â€‹= â€‹846.2 â€‹± â€‹166.0 vs. 743.1 â€‹± â€‹124.7; O2pulse â€‹= â€‹24.5 â€‹± â€‹1.4 vs. 23.1 â€‹± â€‹1.3 (p<0.05). Experiment 2 PMP vs. NMP, respectively: V ˙ O2peak â€‹= â€‹43.3 â€‹± â€‹1.6 vs. 41.7 â€‹± â€‹1.6 (p<0.05); V ˙ O2@VT â€‹= â€‹31.1 â€‹± â€‹1.2 vs. 29.1 â€‹± â€‹1.3 (p<0.05); GXT-TTE â€‹= â€‹511.7 â€‹± â€‹49.6 vs. 486.4 â€‹± â€‹49.6 (p<0.05); VTER 872.4 â€‹± â€‹134.0 vs. 792.9 â€‹± â€‹122.4; O2pulse â€‹= â€‹24.1 â€‹± â€‹0.9 vs. 23.4 â€‹± â€‹0.9 (p<0.05). Results demonstrate that the PMP conferred a significant performance benefit to cyclists completing high intensity cycling exercise.

The Outpatient DIEP: Safety and Viability following a Modified Recovery Protocol.

BACKGROUND: Breast reconstruction with autologous tissue is considered the current state-of-the-art choice following mastectomies, and the deep inferior epigastric perforator (DIEP) flap is often among the favored techniques. Commonly referred to patients as a combination between a tummy tuck and a breast augmentation, it significantly differs by the required expertise and long hospital stays. We present a series attesting to the feasibility and effectiveness of performing this type of reconstruction in an outpatient setting following our recovery protocol. METHODS: Patients undergoing DIEP flap breast reconstruction followed a recovery protocol that included intraoperative local anesthesia, microfascial incision technique for DIEP harvest, double venous system drainage technique, rib and chest muscle preservation, and prophylactic anticoagulation agents. RESULTS: Fourteen patients totaling 27 flaps underwent breast reconstruction following our protocol. All patients were discharged within the initial 23 hours, and no take-backs, partial, or total flap failures were recorded. A case of abdominal incision breakdown was seen in 1 patient during a postoperative visit, without evidence of frank infection. No further complications were observed in the 12-week average observation period. CONCLUSION: With the proper use of a microfascial incision, complemented by rib sparing and appropriate use of injectable anesthetics, routine breast reconstructions with the DIEP flap can be safely performed in an outpatient setting with discharge in the 23-hour window.

Restoration of Elbow Flexion in Patients With Complete Traumatic and Obstetric Brachial Plexus Injury After Functional Free Gracilis Muscle Transfer: Our Experience and Management.

Background: Functional free gracilis muscle transfer is an operative procedure for elbow reconstruction in patients with complete brachial plexus nerve and avulsion injuries and in delayed or prolonged nerve denervation, as well as in patients with inadequate upper extremity function after primary nerve reconstruction. Methods: We retrospectively reviewed our patient records and identified 24 patients with complete brachial plexus nerve injury (13 obstetric, 11 males and 2 females; 11 traumatic, 9 males and 2 females) whose affected arm and shoulder were totally paralyzed and their voluntary elbow flexion or the biceps function was poor preoperatively (mean M0-1/5 in MRC grade). These patients had undergone the functional free gracilis muscle transfer procedure at our clinic since 2005. Results: Ninety-two percent of all patients showed recovery and improvement. Successful free gracilis muscle transfer is defined as antigravity biceps muscle strength of M3-4/5 and higher, which was observed in 16 (8 obstetric and 8 traumatic) of our 24 patients (67%) in this study at least 1 year after functional free gracilis muscle transfer. This is statistically significant (P < .000001) in comparison with their mean preoperative score (M0-1/5). There was no improvement in motor level of the biceps muscle (M0/5) in 2 patients (1 from each group). The donor site of these 24 patients showed no deficit in motor and sensory functions. Conclusions: Taken together, a significant number (92%) of patients in both obstetric and traumatic brachial plexus injury groups had recovery and improvement and most of these patients (64%) achieved antigravity and elbow flexion at least 1 year after free gracilis muscle transfer at our clinic.

The Nipple-Areola Preserving Mastectomy: The Value of Adding a Delay Procedure.

BACKGROUND: Conservative mastectomy procedures, such as the nipple-sparing mastectomy (NSM), present appealing options for patients with small invasive or noninvasive malignancies and those needing prophylactic mastectomies. Despite outstanding postoperative cosmetic results, nipple-areola complex (NAC) and mastectomy skin flap (MSF) survival remains a concern. We present our two-stage nipple-areola preserving (NAP) mastectomy, which aims to decrease the rate of NAC loss and MSF necrosis after conservative mastectomies. MATERIAL AND METHODS: Seventy patients who underwent NSM because of malignant and benign conditions were divided into 2 groups: those who underwent our two-stage NAP mastectomy were matched to the group of mastectomy patients without preservation techniques. Demographic data and postoperative results were retrospectively assessed. RESULTS: The NAP group comprised 45 flaps (24 patients), and the NSM group comprised 75 flaps (46 patients). None were actively smoking. The mean time between the delay of the flap and breast reconstruction was 17.6 days (range, of 10-35 days) in the NAP group. No signs of NAC vascular compromise were observed in the NAP group. Nipple necrosis rates were significantly greater (P = 0.0136) in the NSM group: 9 cases in the NSM group versus none within the NAP group. Two patients within the NAP group required nipple excision at the time of their mastectomies after biopsies performed at the time of the NAC delay were positive for malignancy or atypia. CONCLUSIONS: Vascular delay techniques favor the blood supply of a tissue after a surgical wound, effectively improving the survival of the NAC and MSF after nipple-sparing mastectomies.

The Nipple-Areola Preserving Mastectomy: A Multistage Procedure Aiming to Improve Reconstructive Outcomes following Mastectomy.

UNLABELLED: Ischemia of the nipple-areola complex (NAC) and periareolar tissue is commonly seen following tissue-preserving mastectomies for small invasive and noninvasive cancers. The nipple-areola preserving mastectomy is a multistage procedure in which the NAC and central mastectomy flap tissue is surgically delayed to improve the survivability in patients undergoing mastectomies followed by reconstruction. METHODS: We conducted a retrospective chart review of 20 patients undergoing the 2-stage nipple-areola preserving mastectomy: the first stage comprised undermining the NAC and raising the breast skin flaps, with placement of a silicone sheet in the dissected pocket. The second stage followed 2-3 weeks after the NAC delay, with patients undergoing nipple-sparing mastectomies. RESULTS: Mean age was 46.2 years (range, 23-59 years). Indications included breast cancer in 18 patients and BRCA gene mutation prophylaxis in 2 patients. None were actively smoking. Mean time between delay of flaps and breast reconstructions was 16 days (range, 10-35 days). One patient underwent bilateral nipple resection at the time of mastectomies due to a subareolar nipple biopsy positive for ductal carcinoma in situ. One patient underwent left nipple excision after a skin nipple biopsy was positive for metaplasia. No signs of NAC vascular compromise were observed in any of the cases. CONCLUSIONS: Our 2-stage approach benefits patients undergoing nipple-sparing mastectomy, especially those at high-risk, by safely increasing survivability of the native breast skin envelope and NAC, while improving oncologic outcomes by identification of subareolar malignancies and sentinel node status before mastectomy and reconstruction.

Delayed Mammoplasty with Silicone Gel Implants following DIEP Flap Breast Reconstruction.

UNLABELLED: The deep inferior epigastric artery perforator (DIEP) flap is a state-of-the-art option for breast reconstruction. However, thin patients with medium- to large-size native breasts are not ideal candidates due to the limited amount of available tissue. We reviewed our experience utilizing the DIEP flap in combination with prosthetic implants. METHODS: We conducted a retrospective chart review of 7 patients, totaling 11 implants, who underwent breast reconstruction with the DIEP flap and subsequent mammoplasty. All cases underwent previous mastectomies. No implant placement was offered at the time of their DIEP flap reconstruction. Immediate breast reconstruction with the DIEP flap was performed in 9 cases, whereas 2 required delayed reconstruction secondary to postmastectomy radiotherapy. No patients received postreconstruction radiotherapy. Breast asymmetry and inadequate volume were the primary indications for mammoplasty. For all cases, we used smooth, round silicone gel implants, which were placed in the subpectoral region. RESULTS: Mean age was 43 years. One patient was actively smoking. Four patients underwent bilateral implant placement. The mean time of delay between breast reconstruction and mammoplasty was 61 weeks. Average volume of silicone implants was 229 mL. A medial pedicle vertical mastopexy was performed in 1 patient on a nonreconstructed breast to achieve symmetry. Five patients underwent nipple reconstruction. All patients underwent delayed mammoplasty without intraoperative complications and good aesthetic results. CONCLUSIONS: Delayed mammoplasty following DIEP flap breast reconstruction is a safe and feasible procedure for patients who seek an aesthetic and natural-looking breast but lack adequate abdominal tissue.

Chin surgery III: revelations.

This article is a logical extension of previous articles written on the topic of aesthetic chin surgery. In it, the authors expand on previously published surgical techniques and provide specific updates to increase success in some unusual situations. They review the indications for and uses of reduced-height implants, discuss the validity of centralized chin incisions in both reconstruction and revisions, show the diversity of mentalis muscle anatomy and chin pad variations, reveal the importance of the lip-to-labiomental crease inclination in cases of macrogenia, note a key update on reefing the mentalis muscle to a higher position for permanent sulcus position, discuss the issues of lower lip position and lower incisor show, and expound on the horizontal smile/chin ptosis phenomenon.

The temporal sequence of periosteal attachment after elevation.

This study investigated the adherence of periosteum to bone after elevation to document the temporal sequence of healing at the periosteal/bone interface. There has been a lack of consensus among surgeons as to the time required for healing at this interface; some believe that the healing achieves significant strength in a few days, whereas others believe that the periosteum does not adhere to the bone for many weeks. The aim of this study was to document the time course for healing, completeness of the reattachment, and structural characteristics of the union of bone and periosteum. To test the hypothesis, scalp flaps were elevated in a subperiosteal plane and were reattached in 40 adult guinea pigs and controls. The individual groups were studied at 3, 6, 12, 30, and 90 days postoperatively. Postmortem study consisted of analysis of the mechanical and histologic findings. Strength of adherence was documented by measuring the force required for reverse avulsion of the flaps with an Instron Mini 44 tensiometer. The specimens were also submitted for electron microscopic examination. The mean tension recorded in the plateau phase of avulsion of the flaps was as follows: controls, 78 g; experimental at 3 and 6 days, not applicable (weak adherence not permitting exposure for reverse avulsion); 12 days, 39 g (p = 0.0001); 30 days, 58 g (p = 0.0012), and 90 days, 63 g (p = 0.0229). There was a significant difference between all groups and the controls. Electron microscopic study showed collagen deposition at the bone periosteal interface, which became progressively more organized in the groups studied at 30 and 90 days, with decreasing amounts of inflammation and inflammatory cells. This study demonstrated that healing at the bone/periosteal interface progresses at a rate consistent with healing of most other wounds, dispelling many widespread beliefs that the adherence at this interface was accelerated. The temporal sequence of healing at the periosteal bone interface should be considered in the various procedures in which periosteal flaps are elevated. For example, there is clinical relevance in subperiosteal brow lift procedures, in which the periosteum should be reattached by a fixation technique that will remain stable for a minimum of 30 days to allow adequate adherence between the bone and periosteum at the postoperative elevated brow position.

Double venous system drainage in deep inferior epigastric perforator flap breast reconstruction: a single-surgeon experience.

BACKGROUND: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap has many advantages. The main drawback is the technical difficulty and risk of failure. Many flap failures are the result of venous insufficiency. The author explored the routine use of double venous system anastomosis in DIEP flap breast reconstruction. METHODS: In all consecutive DIEP flaps performed by the author from June 1, 2008, to July 1, 2012, in which it was technically feasible, a superficial vein was dissected and anastomosed to either an internal mammary perforating vein or a second vena comitans. Patient charts were reviewed for flap failure or return to the operating room for exploration of suspected vascular insufficiency. A standard chi-square test and Yates corrected chi-square test were used for analysis. RESULTS: Three hundred fifty-two DIEP flaps were performed on 192 patients in the study period. In 311 of 352 flaps (88.4 percent), double venous system anastomosis was possible. There were no flap failures in either group. In the double venous system group, there was one (0.3 percent) return to the operating room for venous congestion. In the single venous system group, there were two (4.9 percent). Chi-square analysis showed statistically significant reduction in operative explorations in the double venous system group (value of 8.9; p = 0.0029). A Yates correction, applied because of the low number of reoperations in both groups, also showed a statistically significant reduction (value of 4.3; p = 0.038). CONCLUSION: Double venous system anastomosis statistically reduced operative take-backs in this study.

The lateral port control pharyngeal flap: a thirty-year evolution and followup.

In 1971, Micheal Hogan introduced the Lateral Port Control Pharyngeal Flap (LPCPF) which obtained good results with elimination of VPI. However, there was a high incidence of hyponasality and OSA. We hypothesized that preoperative assessment with videofluoroscopy and nasal endoscopy would enable modification and customization of the LPCPF and result in improvement in the result in both hyponasality and obstructive apnea while still maintaining results in VPI. Thirty consecutive patients underwent customized LPCPF. All patients had preoperative diagnosis of VPI resulting from cleft palate. Patient underwent either videofluoroscopy or nasal endoscopy prior to the planning of surgery. Based on preoperative velar and pharyngeal movement, patients were assigned to wide, medium, or narrow port designs. Patients with significant lateral motion were given wide ports while patients with minimal movement were given narrow ports. There was a 96.66% success rate in the treatment of VPI with one patient with persistent VPI (3.33%). Six patients had mild hyponasality (20 %). Two patients had initial OSA (6.67%), one of which had OSA which lasted longer than six months (3.33%). The modifications of the original flap description have allowed for success in treatment of VPI along with an acceptably low rate of hyponasality and OSA.

The tear trough and lid/cheek junction: anatomy and implications for surgical correction.

BACKGROUND: The tear trough and the lid/cheek junction become more visible with age. These landmarks are adjacent, forming in some patients a continuous indentation or groove below the infraorbital rim. Numerous, often conflicting procedures have been described to improve the appearance of the region. The purpose of this study was to evaluate the anatomy underlying the tear trough and the lid/cheek junction and to evaluate the procedures designed to correct them. METHODS: Twelve fresh cadaver lower lid and midface dissections were performed (six heads). The orbital regions were dissected in layers, and medical photography was performed. RESULTS: In the subcutaneous plane, the tear trough and lid/cheek junction overlie the junction of the palpebral and orbital portions of the orbicularis oculi muscle and the cephalic border of the malar fat pad. In the submuscular plane, these landmarks differ. Along the tear trough, the orbicularis muscle is attached directly to the bone. Along the lid/cheek junction, the attachment is ligamentous by means of the orbicularis retaining ligament. CONCLUSIONS: The tear trough and lid/cheek junction are primarily explained by superficial (subcutaneous) anatomical features. Atrophy of skin and fat is the most likely explanation for age-related visibility of these landmarks. "Descent" of this region with age is unlikely (the structures are fixed to bone). Bulging orbital fat accentuates these landmarks. Interventions must extend significantly below the infraorbital rim. Fat or synthetic filler may be best placed in the intraorbicularis plane (tear trough) and in the suborbicularis plane (lid/cheek junction).

Morphology and growth of the mandible in Crouzon, Apert, and Pfeiffer syndromes.

The purpose of this study was to examine mandibular morphology and growth in patients with Crouzon, Pfeiffer, and Apert syndromes using posteroanterior cephalograms. Fifteen patients with Apert (n = 2), Crouzon (n = 11), and Pfeiffer (n = 2) (11 female, 4 male) syndrome were included in this study. All patients had serial posteroanterior cephalograms at 5, 10, and 15 years of age. The bicondylar width, bigonial width, bicondylar/bigonial ratio, and ramus to intercondylar plane angle for each patient were measured on the cephalograms and compared with age-match controls. An analysis of variance analysis was carried out to detect differences between patients and controls and sex differences between patients. In both male and female patients, there was a statistically significant reduction in bicondylar width compared with age-matched controls. Male patients also had a statistically significant increase in bigonial width compared with controls and female patients at 10 and 15 years. The resulting bicondylar/bigonial ratios were significantly reduced, and the ramus to intercondylar plane angles were significantly increased in both male and female patients compared with controls. Unlike previous reports of patients with syndromic synostosis, this study demonstrates that the mandible has significant morphologic and growth abnormalities, including constriction of bicondylar width with near normal bigonial width in female patients. These findings suggest a narrowing at the cranial base with resulting restriction of normal transverse mandibular growth at the condyle. The secondary nature of the mandibular finding is suggested by the near normal or increased transverse growth at the gonion in females and males, respectively. Consequently, the ramus appears torqued inward, forming a greater angle with the cranial base.